Given that research does not inhabit a moral vacuum and weighing up the contingent status of research, my response to this kind of dilemma was clearly a pragmatic one. In order to initiate any level of change I usually resorted to questioning staff about the rationale for policies and practices. This served a dual purpose of firstly attempting to avoid prejudging behaviours without understanding the context in which they took place. Secondly, I hoped through these means that my questions would spark a process of reflection in my respondent that would challenge established attitudes on the ward leading to change at this point in the hierarchy of power.
The following chapter moves away from the interpersonal negotiations, practical and ethical dilemmas and the basic mechanics of contemporary data gathering to offer a critical review of the nature of asylum care historically, in an attempt to delineate more clearly the connection between eras and philosophies of care, as they relate to the Malaysia.
3
Psychiatry and the colonial enterprise in historical Malaya and Borneo
The historical context in Europe
Specifically aimed psychiatric treatment of mentally ill patients in the West has only been in existence since the Enlightenment, and this type of care has in many ways changed almost out of recognition from early concepts of mental illness and appropriate methods of management. In England prior to the era of the county asylum in the nineteenth century, mental illness was primarily managed at home, the poorhouse, prison or the punitive atmosphere of the workhouse. Scull (1979) argues that, by the mid-eighteenth century, the status of madness was being redefined as a condition subject to medicalised expertise rather than one of individual inadequacy.
This period saw the beginnings of a consciousness that the insane could be treated rather than merely contained. General institutional care in Europe prior to this has been condemned for its brutality, with the mad treated like wild animals, that were moreover judged to be impervious to pain, cold, hunger and foul accommodation.
The whole system of treatment was also predicated on the assumption that mental patients are habitually disordered, malicious, base creatures. Every attempt was made to force them to renounce their foolishness and bring them to submission by abusing and punishing them (Kraepelin, 1962: 24).
Porter (2006) points out how little research has been done on the care of the insane prior to the eighteenth century. Thus our knowledge of this area remains patchy. Yet the later, and often callous, incarceration of incorrigibles - typified by the frightful descriptions of one James Norris, a ‘lunatic’ kept for well over a decade encased in leather and metal restraints - saw the concept of the asylum evolve to one in which the asylum in itself could be seen as therapeutic and a means of achieving a cure (Scull, 1993). This revolutionary idea followed from the logic of the period, whereby rationality was seen to sweep away the superstitions and rigid social structures of the Middle Ages, articulated, for example, through the measured reasoning of William Battie, a founding member of one of the new public sector asylums, St Luke’s Hospital in London (Shorter, 1997).
Madness is … as manageable as many other distempers, which are equally dreadful and obstinate, and yet are not looked upon as incurable; such unhappy objects ought by no means to be abandoned, much less shut up in loathsome prisons as criminals or nuisances to the society (Shorter, 1997: 10).
The idea of the ‘therapeutic benefits’ of the asylum was one that was consequently transported to the American colonies, and in due course to all other corners of the British Empire, including Malaya, over the following two centuries.
Foucault, as is well known, argued that the eighteenth century was the period that saw the establishment of the great and universal ‘complicity between government and Church’ in Europe, replacing earlier measures of support or oppression of the poor and infirm (Littlewood and Lipsedge, 1989: 32; Foucault, 1966; Foucault, 1976a). In evidence of this Foucault (1966) points to bureaucratically centralised France, where by 1798 there were in existence 177 State sector custodial institutions, of which the most famous were Bicêtre, for male patients, and Salpêtrière for females.
This argument, however, is contested by both Andrew Scull (1993) and Peter Barham (1992) as being unrepresentative of the situation in England at that time, where institutions were largely private, entrepreneurial ventures, rather than State-governed. In accord Shorter (1997) states that there was slow development of the public-sector traditional asylum in England, which numbered only seven charity-run institutions apart from Bethlem and the numerous privately-run institutions. These served to modestly supplement the numerous privately run institutions, where the early version of the ‘alienist’ practiced or attended the afflicted wealthy in their own home. Furthermore, despite the rise of asylums in England at this time, admission numbers remained remarkably low:
By 1826, when national statistics became available in England, only minimal numbers of individuals found themselves in either private or public asylums. Not quite five thousand insane people confined in any form, 64 percent of them in the private sector, 36 percent in the public. Bethlem and St Luke’s together numbered only 500 patients, and a further 53 insane individuals were in jails – this in a country of 10 million people (Shorter, 1997: 5).
In keeping with the new spirit of optimism towards the asylum as curative, as opposed to segregatory and punitive, the view that insanity could be retrained into rationality manifested itself in a form of care known as ‘moral treatment’, as exemplified by William Tuke’s institution for mentally ill Quakers, ‘The Retreat’, at York in 1729. Here the emphasis lay equally upon firmness but kindness in dealing with the antics of the insane, helping them to conform to the boundaries of rational behaviour and civil discourse, with work playing an important part in occupying hands and minds (Black, 1988). As Porter (1983: 36) elegantly states, the Enlightenment drew upon the analogies of wider State politics and the individual psyche to create the representation of the ‘rational government of the parts, madness the appetites’ insurrection’. Foucault’s (1971) analysis of power and madness accordingly argues that Tuke’s demand for rational behaviour among residents was the less than benign substitution of the (terrifying) freedom of madness from normal constraints by the madman, to the imposition of the crushing awareness of self-responsibility.
Moral treatment was not applied to the mentally ill alone, for in the American colonies it was also considered appropriate care for physical illnesses, in which there was displayed as considerable a concern for moral and spiritual aspects, as for physical rehabilitation (Luchins, 1989).
The ideology behind hospital admissions during this period was consequently based more on ‘social and moral criteria than on the nature of the person’s illness’ (Luchins, 1989: 587). Perhaps not surprisingly, given such rationale, we learn that hospitals in the late eighteenth and early nineteenth century were regarded as highly stigmatising charitable institutions. Moral treatment in hospitals, similar to asylum care under the same philosophy, emphasised the removal of afflicted individuals from the contaminating influences of their home and peer environment, thus rehabilitating them into ‘humane, civil, productive and responsible citizens’ able to withstand the ‘temptations of their neighborhoods’ (Luchins, 1989:587).
The concept of the ideal asylum evolved from the eighteenth up to the twentieth centuries and was seen to be one that was designated into functional areas, which in turn would be replicated through reinterpretation in the colonies These areas provided, in literally concrete terms, a means